Pyschological issues	Symptom control
Education	Management of infertility
Diet and lifestyle	Long term sequelae

Psychological issues

See also Early Menopause and Emotional Wellbeing

 Early Menopause and Emotional Wellbeing (71.36 KB)

Limited evidence suggests that women who experience premature menopause have higher rates of depression and anxiety, have a more negative body image, are more likely to be negative about their health, have low self esteem and impaired sexual function (see Table: Risk factors for depression). Experiencing an event such as menopause outside the normal life stage (i.e. usually at 50 years) is likely to be distressing.

The reason for the premature menopause, the individual and social situation of each woman such as whether she is in a relationship, whether she has children already, her support networks and lifestyle are all likely to impact on the experience. How women think, feel and behave in relation to their present and future health is also of concern for women with premature menopause. Counseling, providing women with an opportunity to express their emotions and referral to psychologist / psychiatrist may be necessary.

Referral to a support group may also be useful -
New Zealand support group: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Education

Increased patient satisfaction was reported by women with premature menopause when longer than 5 minutes was spent discussing the diagnosis and the woman was referred to other sources of information. Compliance with long-term hormone therapy is dependent on the patient's understanding of long-term sequelae.

 Early Menopause (103.15 KB)

 Early Menopause and Emotional Wellbeing (71.36 KB)

Diet and lifestyle

Modification of dietary and lifestyle factors assists menopausal symptom control, improvement of psychological symptoms and cardiovascular disease and osteoporosis risk reduction (see Table: Diet and Lifestyle).

See also Healthy Lifestyles, Nutrition, Other Therapies 

Table: Diet and Lifestyle

Symptom control Wear layered clothing, use fans, set thermostat lower Avoid spicy food Moderate caffeine and alcohol intake Increase dietary phytoestrogen intake Regular exercise

Reduce cardiovascular disease risk

Reduce osteoporosis disease risk

 Bone Health (65.74 KB)

 Dr Rick’s 10 Top Tips to be a healthy weight (87.22 KB)

 Healthy Eating (102.59 KB)

 Nutritional Tips (93.71 KB)

 Physical Activity (86.67 KB)

Symptom control

Hormone Replacement Therapy

The use of hormone replacement therapy (HRT) to treat the symptoms of oestrogen deficiency (in those women without contraindications to oestrogen) is generally accepted. However, there is no consensus regarding the best form of HRT in women with premature menopause or how long treatment should continue.

 There is no data directly applicable to this patient group regarding the use of HRT for long-term complication prevention or safety of HRT. The general belief is that treatment should be initiated early and continued until approximately the age of natural menopause (approximately 50 years).

Therapy is best individualised using HRT regimens currently available or the oral contraceptive pill (OCP).

Younger women frequently require higher doses of oestrogen (equivalent to 1.25mg conjugated equine oestrogen) for symptom control and maintenance of bone mineral density (BMD). In those women with an intact uterus where combined oestrogen + progestagen HRT is required, discussion with the individual woman is important. A monthly withdrawal bleeding can be psychologically important to some women and development of amenorrhea in women on cyclical HRT may indicate pregnancy in those with spontaneous premature ovarian failure (POF).

Although current data in older postmenopausal women is reassuring, the endometrial safety of long-term continuous progestagen in young women is unknown. The conventional doses of HRT do not prevent spontaneous ovulation or conception. Thus the use of the low dose OCP is indicated if a woman with spontaneous POF does not desire pregnancy.

Non-hormonal Therapies

Non-hormonal therapies available for use in older postmenopausal women with contra-indications to oestrogen are appropriate for use in women with early menopause. A recent meta-analysis and systematic review by Nelson and co-workers of non-hormonal therapies including antidepressants, antihypertensives, gabapentin, red clover and soy isoflavone extracts provided supportive evidence for efficacy of paroxetine, venlafaxine, gabapentin and clonidine (and mixed results for soy isoflavones) in reducing the frequency of hot flushes. However, the magnitude of this effect was small with a calculated reduction of 1-2 hot flushes per day. Many of these studies were of short duration and conducted in women with breast cancer. Thus, the relevance to women with premature menopause and the long-term efficacy and safety of these therapies remains unknown.

Women with breast cancer may experience hot flushes due to chemotherapy induced early menopause / premature menopause, oophorectomy  and/or secondary to treatment with tamoxifen or an aromatase inhibitor. The non-hormonal therapies described above may be useful in this setting; however, there is evidence of paroxetine interference with tamoxifen metabolism and these medications should not be prescribed concurrently.

See also Androgen Therapy

Natural Therapies

The efficacy and safety of phytoestrogens or other herbal / complementary preparations is not established in this patient population. A discussion of their potential uses is described in the section Natural Therapies.

See Complementary therapies/Natural therapies  

Management of infertility

See Premature Ovarian Failure – Infertility

Long-term Sequelae

Women with early menopause are at risk of long term complications relating to both the specific cause of premature menopause as well as those relating to women with premature menopause generally.

Monitoring of the long-term complications associated with specific causes of premature menopause (e.g. Turner's syndrome) is necessary. Although the natural history of associated autoimmune dysfunction is ill-defined in women with POF, yearly TFTs and fasting glucose is recommended. Recurrent malignancy is a concern where premature menopause occurs secondary to cancer therapy.

Cardiovascular Disease

The risk of cardiovascular disease is increased in women with premature menopause and is the main contributing factor to the twofold increase risk of premature death observed in these women. The pathophysiological factors contributing to atherosclerosis associated with oestrogen deficiency include: adverse lipid profile and endothelial dysfunction. In one small study administration of oral cyclical HRT to women with POF improved lipid parameters and restored endothelial function to normal after 6 months. The "timing hypothesis" proposes that oestrogen may exert atheroprotective effects in younger women without established atherosclerotic plaques but in older women with established atherosclerosis oestrogen may exert harmful pro-thrombotic and pro-inflammatory effects. Concern regarding the results of the Women's Health Initiative (WHI) has led to reluctance on the part of patients to take or practitioners to prescribe HRT to young women. However, the average age of participants in WHI was approximately 63 years, so its relevance to women with premature menopause is debatable. Indeed, WHI data indicates no significant increase in the risk of coronary heart disease in women aged 50-59 years receiving HRT compared with increased risk in older women. Management follows usual principles with treatment of modifiable risk factors, anti-hypertensives and lipid lowering agents as appropriate.

Osteoporosis

Osteopaenia is common in women with premature menopause although the degree of BMD loss varies between different cohorts of women. Risk factors for osteoporosis which need to be considered in women with premature menopause are shown in Table: Risk Factors for osteoporosis. Therapy follows conventional measures with dietary and lifestyle factors and calcium / vitamin D supplementation where indicated. HRT is indicated. The role of bisphosphonates, strontium ranelate, raloxifene, and androgens is less clear.

See also Bone Health for Life www.bonehealthforlife.org.au

 Bone Health (65.74 KB)

Table: Risk Factors for Osteoporosis

Low calcium intake

Smoking

Excess alcohol, caffeine

Low vitamin D Cultural - veiled or covered women Dark skin

Hyperthyroidism

Coeliac disease

Medication including corticosteroids, thyroxine, aromatase inhibitors, anticonvulsants

Positive family history

Previous atraumatic fracture

Breast Cancer

Observational studies indicate a decreased risk of breast cancer in women with premature menopause. The effect of HRT on breast cancer risk in this group of women has not been addressed specifically.

Cognitive function

The effect of premature menopause on cognitive function and the risk of Alzheimer’s disease remains unclear. A recent observational study (Rocca et al., 2007 Neurology, 69;1074-1083) reported an increased risk of cognitive impairment or dementia in women who experienced surgical menopause before 49 years of age. However, women who were given oestrogen therapy following oophorectomy before age 49 and used it until at least age 50 years showed no increased risk of dementia or cognitive decline. This finding is consistent with earlier short-term randomised controlled trials which demonstrated beneficial effects of oestrogen therapy in women (mean age 45 years) following oophorectomy (reviewed by Sherwin, 2003). Cognitive dysfunction has been reported after adjuvant chemotherapy for breast cancer.

Content updated December 5, 2007